Chandigarh

DF-II

CC/77/2016

Dinesh Rana - Complainant(s)

Versus

The Oriental Insurance Company Limited - Opp.Party(s)

P.C. Rana Adv.

06 Oct 2016

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II, U.T. CHANDIGARH

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Consumer Complaint  No	:	77 of 2016
Date  of  Institution	:	02.02.2016
Date   of   Decision	:	06.10.2016

 

 

 

 

1]  Dinesh Rana son of Sh.Hoshiar Singh Rana, resident of House NO.2399/1, Sector 40-C, Chandigarh.

2]  Pushpa Rana w/o Sh.Dinesh Rana, R/o H.No.2399/1, Sector 40-C, Chandigarh.

             …..Complainants

Versus

1]  The Oriental Insurance Company Limited, through its authorised representative, SCO No.109-111, Sector 17-D, Chandigarh.

2]  The Oriental Insurance Company Limited, A-25/27, Asaf Ali Road, New Delhi – 110002 through its Managing Director

3]  Medi Assist India TPA Pvt. Ltd., SCO 521, IInd Floor, Sector 70, Mohali (Punjab)

….. Opposite Parties  

 

BEFORE:  SH.RAJAN DEWAN                 PRESIDENT

         MRS.PRITI MALHOTRA             MEMBER

 

 

For complainant(s)      : Sh.P.C.Rana, Counsel for the complainants.

 

For Opposite Party(s)   : Sh.Ram Avtar, Counsel for the OPs.

 

 

PER PRITI MALHOTRA, MEMBER

 

 

          As per the case, the complainant No.1 purchased a PNB-Oriental Royal Mediclaim Policy bearing No.231203/48/2015/1532 for himself and his family members, which includes his wife/complainant NO.2 and son, effective from 13.2.2015 to 12.2.2016 with sum insured upto 5 lacs by paying the requisite premium (Ann.C-1 to C-3) and that the 3 days lapse in renewing the present policy, was condoned by the OPs as the earlier policy had expired on 10.2.2015.  It is averred that however, the OPs never issued any policy document or booklet, which includes the terms & conditions, to the complainants despite repeated requested except Ann.C-1. It is stated that the complainant NO.2 suddenly got pain in stomach on 10.8.2015 and as such visited Dr.Inderjeet Goyal, who diagnosed her with stone of 13.6mm in gall bladder (Ann.C-4 & C-5).  Then complainant NO.2 was admitted in P.N.Urology and Surgical Hospital, Sector 40-B, Chandigarh on 20.9.2015 and operated for stone in gall bladder on the same date and discharged on 21.9.2015.  It is also submitted that an amount of Rs.40,158/- was spent on the said treatment (Ann.C-6 colly, C-7 to C-9 colly.).  Thereafter, a claim was lodged with the OPs seeking reimbursement of medical expenses incurred on the treatment of complainant NO.2 (Ann.C-10 & C-11) followed by e-mails (Ann.C-12 colly).  However, the OPs did not settle the claim filed by the complainants despite number of efforts made.  Hence, this complaint has been filed alleging the above act of the OPs as deficiency in service.

 

2]       The OPs have filed joint reply and admitted the issuance of insurance policy in favour of the complainants and filing of claim by the complainants. It is pleaded that the claim of the complainants falls under the exclusion clause 4.2 and as per the policy terms & conditions, the claim is not payable. It is also pleaded that the expenses on treatment of surgery of gallbladder and Bile Duct excluding malignancy for specified period of two years are not payable if contracted/manifested during the currency of policy. It is stated that as the policy availed by the complainants is in second years, so the claim was not payable.  It is also stated that the claim falls within the exclusion clause 4.2, therefore, the same was rightly repudiated by the OPs. Rest of the allegations have been denied with a prayer to dismiss the complaint.

 

3]       Rejoinder has also been filed by the complainant thereby reiterating the assertions made by the complainants and controverting that of the OPs made in their reply.

 

4]       Parties led evidence in support of their contentions.

 

5]       We have heard the ld.Counsel for the parties and have also perused the record as well as written arguments.  

6]       It is argued on behalf of the complainants that the claim raised by the complainants under the policy obtained by them from the OPs was wrongly repudiated.  Challenging the repudiation of the claim by the OPs, it is claimed that no terms & conditions were ever supplied to the complainants and also not explained the same by the OPs. 

 

7]       On the contrary, the ld.Counsel for the OPs submitted that the claim of the complainant fall under the exclusion clause 4.2 and as per the policy terms & conditions, the claim is not payable for the reason that the expenses on treatment of surgery of gallbladder and Bile Duct excluding malignancy for specified period of two years are not payable if contracted/manifested during the currency of policy. It is also claimed that since the policy availed by the complainants is in second years, so the claim was not payable.

 

8]       The OPs have not disputed that the complainants have availed PNB-Oriental Royal Mediclaim Policy bearing NO.231203/48/2015/1532 for family including son, effective from 13.2.2015 to 12.2.2016 with sum insured upto Rs.5.00 lacs.  It is well proved on record that the above said policy, obtained by the complainant was considered as the renewal policy despite there being a 3 days lapse in renewing the present policy as the OPs condoned the gap of three days period (Ann.C-1).  There is also no dispute regarding the fact that the complainant No.1’s wife i.e. complainant No.2 also covered under the said policy, was diagnosed with stone of 13.6mm in gall bladder, for which treatment was prescribed by the doctors and accordingly, was availed from P.N.Urology and Surgical Hospital, Sector 40-B, Chandigarh from 20.9.2015 to 21.9.2015.  The claim for the expenses incurred on the said treatment of complainant NO.2 was lodged with the OPs, which they rejected vide rejection letter dated 08.02.2016 (re-written as 8.3.2016).  The reason for the rejection of the claim, as explained in the rejection letter (Ann.R-2), is reproduced as under:-

“We have received your claim file duly processed by the TPA with the following observations, “Patient admitted in P.N.UROLOGY & SURGERY HOSPITAL on 20/09/2015 with and diagnosed as a case of CHOLELITHIASIS was done.  Policy inception date is 11/02/2014.  Policy running in 2^ND year.  Present ailment is not payable in first two year.  Hence, this claim is denied under Excl. 4.2 hence, we regret our inability to admit this liability under the present policy conditions and this claim is being repudiated and same is not payable.”  

 

9]       The OPs also mentioned the relevant exclusion clause 4.2, which also reads as under:-

 

Relevant Exclusions read as under:

4.2. The expenses on treatment of following ailment/diseases/surgeries for the specified periods are not payable if contracted and/or manifested during the currency of the policy

S.No.	Ailment/Disease/Surgery	Waiting Period
xiii	Surgery of gallbladder and bile duct excluding malignancy.	2 years

 

10]      The complainant has vehemently argued that the repudiation on the above mentioned clause by the OPs, is not applicable in this case, as the complainants were not supplied any of the terms & conditions of the policy in question at any point of time by the OPs. The complainants have also raised this plea in the rejoinder filed and in the written arguments submitted by them. It is observed that the OPs have failed to bring on record any of the documents showing that the complainants were supplied with the terms & conditions of the policy in question or had ever been explained about the terms & conditions of the same. 

 

11]      The Opposite Parties have also not placed on record any affidavit of any of the officials claiming that the terms & conditions of the policy in question were duly supplied or explained to the complainants at the time of inception of policy or at the time when the said policy was renewed after a lapse of 3 days.  Thus, in view of absence of such record, the repudiation of claim on the basis of terms & conditions, not supplied to the complainant, is totally unjustified and amounts to deficiency in service on the part of the OPs.

 

12]      While arriving to final conclusion, we also put reliance on the judgment of Hon’ble Supreme Court in Civil Appeal No.6895 of 1997 – M/s. Modern Insulators Ltd. Vs. Oriental Insurance Co. Ltd., decided on 22.2.2000 – 2000(1) C.P.J. 1 – wherein in Para No.9 it has been held as under:-

“9.     In view of the above settled position of law we are of the opinion that the view expressed by the National Commission is not correct.  As the above terms and conditions of the standard policy wherein the exclusion clause was included, were neither a part of the contract or insurance nor disclosed to the appellant, respondent cannot claim the benefit of the said exclusion clause.  Therefore, the finding of the National Commission is untenable in law.”      

  

13]      In view of the above discussion, we are of the opinion that deficiency in service on the part of the Opposite parties has been proved and thus, the complaint deserves to be allowed against the OPs. Accordingly, the complaint is allowed and the Opposite parties are jointly & severally directed as under:-

a]  To reimburse an amount of Rs.40,153/- to the complainants;

 

b]  To pay an amount of Rs.10,000/- as compensation for causing mental agony and physical harassment to the complainants due to their deficient services;

 

c]  To pay Rs.7,000/- towards litigation expenses.

 

         The above said order shall be complied with by the Opposite Parties within 45 days of its receipt, failing which they shall be liable to pay interest @18% p.a. on the above awarded amount as at sub-para [a] & [b] above from the date of filing this complaint till it is paid, besides paying litigation expenses.

         The certified copy of this order be sent to the parties free of charge, after which the file be consigned.

Announced

06^th October, 2016                                                                                                                                                                   Sd/-  

 (RAJAN DEWAN)

PRESIDENT

 

 

 

Sd/-  

 (PRITI MALHOTRA)

MEMBER